From the Guidelines
Major Depressive Disorder (MDD) is diagnosed when a person experiences at least five symptoms during the same two-week period, with at least one symptom being either depressed mood or loss of interest/pleasure, as outlined in the diagnostic criteria provided by the American Psychiatric Association 1. The diagnostic criteria for MDD include:
- Depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others
- Markedly diminished interest or pleasure in all, or nearly all, activities most of the day, nearly every day
- Significant weight loss when not dieting or weight gain, or increased or decreased appetite nearly every day
- Insomnia or hypersomnia nearly every day
- Psychomotor agitation or retardation nearly every day
- Fatigue or loss of energy nearly every day
- Feelings of worthlessness or inappropriate guilt nearly every day
- Diminished ability to think or to concentrate, or indecisiveness, nearly every day
- Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt, or a specific plan to commit suicide These symptoms must cause clinically significant distress or impairment and cannot be attributable to another medical condition or substance use.
Treatment Options
Treatment for MDD typically involves psychotherapy, medication, or a combination of both.
- First-line antidepressants include selective serotonin reuptake inhibitors (SSRIs) such as sertraline (50-200mg daily), escitalopram (10-20mg daily), or fluoxetine (20-80mg daily) 1.
- SNRIs like venlafaxine (75-225mg daily) or duloxetine (30-120mg daily) are also commonly used.
- Medication should be started at a lower dose and gradually increased, with treatment continuing for at least 6-12 months after symptom remission to prevent relapse.
- Psychotherapy approaches, particularly cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT), have strong evidence for effectiveness 1. For severe or treatment-resistant depression, options include switching medications, augmentation strategies (adding medications like bupropion, mirtazapine, or atypical antipsychotics), or considering electroconvulsive therapy (ECT). Regular follow-up is essential to monitor response, side effects, and suicide risk, with assessments typically every 1-2 weeks initially, then monthly as symptoms improve.
From the FDA Drug Label
A major depressive episode implies a prominent and relatively persistent depressed or dysphoric mood that usually interferes with daily functioning (nearly every day for at least 2 weeks); it should include at least 4 of the following 8 symptoms: change in appetite, change in sleep, psychomotor agitation or retardation, loss of interest in usual activities or decrease in sexual drive, increased fatigue, feelings of guilt or worthlessness, slowed thinking or impaired concentration, and a suicide attempt or suicidal ideation.
The diagnostic criteria for Major Depressive Disorder (MDD) include:
- A prominent and relatively persistent depressed or dysphoric mood
- Interference with daily functioning (nearly every day for at least 2 weeks)
- At least 4 of the following 8 symptoms:
- Change in appetite
- Change in sleep
- Psychomotor agitation or retardation
- Loss of interest in usual activities or decrease in sexual drive
- Increased fatigue
- Feelings of guilt or worthlessness
- Slowed thinking or impaired concentration
- A suicide attempt or suicidal ideation Treatment options for MDD include:
- Medications: such as duloxetine, venlafaxine, and sertraline
- Dosage: varies depending on the medication and individual patient, but typical doses include 50-200 mg/day for sertraline and 60 mg/day for duloxetine
- Duration of treatment: several months or longer of sustained pharmacologic therapy beyond response to the acute episode 2, 3
From the Research
Diagnostic Criteria for Major Depressive Disorder (MDD)
- The diagnostic assessment of MDD involves evaluating the differential diagnosis, accompanying symptoms, psychiatric and medical comorbidities, and sociodemographic factors 4.
- Diagnosing MDD is challenging, and diagnostic manuals may fail to capture the wide range of clinical symptoms endorsed by individuals with this condition 5.
- The Patient Health Questionnaire-9 (PHQ-9) is excellent at identifying MDD but may overdiagnose the condition 5.
- The use of self-report symptom scales, such as the Diagnostic Inventory for Depression, may be considered as diagnostic criteria for MDD, with performance similar to or superior to some DSM-IV MDD symptom criteria 6.
Treatment Options for MDD
- Tricyclic antidepressants (TCAs) have an important place in the treatment of MDD, but their position appears unclear due to the availability of other antidepressant medications with fewer adverse effects 7.
- The choice of TCAs and dosing strategies is influenced by various factors, including guideline recommendations, clinical practice, and patient characteristics 7.
- Measurement-based care for MDD is feasible in clinical practice, using assessment tools to screen for, diagnose, and treat the disorder 8.
- Treatment algorithms and collaborative care can rationalize decision-making and enhance treatment results 8.
Assessment Tools for MDD
- Many instruments are available to enhance the assessment of MDD at three levels: screening, diagnosing, and monitoring treatment 8.
- Patient self-reports can be used instead of clinician-rated scales to save time, in paper, computerized, or interactive voice response formats 8.
- Assessment tools are available in many languages, making them accessible for diverse patient populations 8.